DACRYOCYSTITIS

Signs and Symptoms

Acute dacryocystitis (lacrimal sac mucocele) is an infection of the lacrimal sac.1-7 It can occur as result of the elements or remnants of trauma, acute or long-standing lacrimal system obstruction or from bacterial infection sourced to the contents of the tear film and or conjunctiva.1-7 Dacryocystitis may also result from an extension of infective and inflammatory processes occurring within the nose or paranasal sinuses.3,4 In some instances, the infection (initially confined to the lacrimal sac) can extend to the soft tissues, causing preseptal cellulitis, or invade the orbital contents, resulting in orbital cellulitis.1-7

Acute dacryocystitis is uncommon in children and young adults under age 30 without a history of congenital nasolacrimal duct obstruction, facial trauma or an underlying systemic condition such as infectious mononucleosis (Epstein-Barr).1,8 The condition is typically unilateral.

Dacryocystitis is more common in the 5th to 6th decade of life, with a mean age of 55.5 years, and can be acute or chronic in nature.1-5 Women tend to have blockages in the nasolacrimal drainage system more often than men, with the highest incidence found in postmenopausal women.1-5 It is thought that this occurs because the bony lacrimal duct is smaller in women than in men.1

Acute dacryocystitis often presents with symptoms of severe pain of the inner canthus in the area of the lacrimal sac just under the medial canthal ligament. Local redness, swelling, epiphora, secondary conjunctivitis, mucoid discharge in the morning and an enlarged, lacrimal sac that is tender to the touch are typical features. Highly diagnostic is mucopurulent discharge regurgitating from the puncta when palpated.1-8 A firm round nodule is often palpable in the setting of adjacent orbital or preseptal cellultis.1-7 Patients with acute disease are rarely febrile.

Pathophysiology

The nasolacrimal ducts consist of the upper and the lower lacrimal canaliculus, the lacrimal sac and the nasolacrimal duct.9-18 They drain the tear fluid from the ocular surface into the lower meatus of the nose.9-18 The puncta define the outermost boundary and beginning of the nasolacrimal apparatus. Each punctum respectively leads into the superior and inferior canaliculus, which extends and expands 2mm in the vertical direction (the superior canaliculus directed superiorly and the inferior canaliculus directed inferiorly) to the ampulla—the reservoir-like anatomic landmark at the base of each 2mm canalicular arm. From there, the canaliculus makes its turn medially toward the nasolacrimal sac.11,12 In 90% of the population, the superior and inferior canaliculi come together to form a common canaliculus that drains into the lacrimal sac.11 In 10% of the population, the superior and inferior canaliculi connect directly into the lacrimal sac.11

The nasolacrimal apparatus continues through the lacrimal sac, which may have a vertical dimension of up to 10mm and exits the sac inferiorly with its fluid flow regulated by both muscular contraction and the valve of Krause.11-13 In the vicinity of the anterior lacrimal crest of the maxillary bone, the lacrimal sac becomes the nasolacrimal duct. It traverses through a bony duct bounded by the lacrimal bone medially and the maxillary bone laterally, encountering the regulatory valve of Rosenmuller.11,12,15 This portion of the duct measures approximately 12mm.11,12,15 An additional 5mm of the lacrimal duct is membranous and opens into the inferior meatus lateral to the inferior turbinate.

The valve of Hasner is situated at the distal end of the duct.11,12,15 This structure functions as a unidirectional valve that allows tears to freely drain out of the lacrimal system into the inferior nasal meatus, preventing retrograde flow.11,12 The valve also functions to block nasal material from entering the system by closing when there is a drastic increase in nasal pressure during events like coughing or sneezing.11,12

The epithelial lining of the lacrimal sac and the nasolacrimal duct is covered by microvilli.9 Antimicrobial defense mechanisms are represented by antimicrobial peptides IgA and immunocompetent cells (lymphocytes and macrophages).9 Under normal circumstances, the embedded blood vessels of the system maintain vegetative control deep within the system in a landmark area referred to as the cavernous body.9 Malfunctions in the cavernous body and/or in its innervations may lead to disturbances in the tear flow cycle, creating ocular congestion or total occlusion of the lacrimal passage.1-19

Any descending infection from the eye or ascending infection from the nose or sinuses can initiate swelling of the mucous membrane, remodeling of the tissues, creating malfunctions in the cavernous body with reactive immunomodulation and occlusion of the lacrimal passage.1-19 Alterations in the ductal epithelium and the lamina propria, encompassing the lacrimal sac and nasolacrimal duct, can permit microbial growth.1-3,19

The most common gram-positive infective organisms include Streptococcus pneumonia, Staphylococcus aureus and Staphylococcus epidermidis, while Haemophilus influenza, Pseudomonas aeruginosa, Serratia marcescens and Klebsiella pneumoniae are the leading the gram-negative bacteria.1,2,20 Mononucleosis and coliform bacteria are rare but documented sources of dacryocyctis.5,21 One unique case documents the organism Pantoea presumed to be obtained through exposure to dog feces.22

Management

Acute onset dacryocystitis in adults is initially managed conservatively with warm compresses, massage, topical antibiotic drops and ointments and a 7-10 day course of oral antibiotics.1-8,20-22 The topical antibiotics of first choice include the fourth-generation fluoroquinolones. However, organisms involved in acute dacryocystitis also respond well to gentamicin and chloramphenicol.1,20-22 The oral antibiotics of first choice include Augmentin (amoxicillin/clavulanoic acid, GlaxoSmithKline), Keflex (cephalexin) and Levaquin (levofloxacin, Ortho-McNeil).21

Gentle digital massage (to express the contents of the sac) can be attempted for lesions discovered early.22 Unfortunately, this therapy tends to be ineffective, with less than 25% of lesions resolving spontaneously or with hot compresses alone.22

Mild cases of dacryocystitis in children often self-resolves without any consideration of dacryocystorhinostomy (DCR) necessary.8 More severe forms of dacryocystitis in children are managed more aggressively as it has a high risk of causing sepsis secondary to an immature immune system.1,20,24 In these instances, admission to the hospital is common so that prompt blood culture, computed axial tomography (CT scan) and IV therapy can be instituted.1,20 Treatment in admitted cases is usually accomplished using intravenous Augmentin.

Probing and biopsy of the nasolacrimal system is not mandatory.25 It must only must be done in cases where there is poor return to function following event resolution or chronic, recurring issues. Standard culture studies can be obtained from discharge and should include blood and chocolate agar, Sabouraud’s media (for fungi), Schaedler media and thioglycolate broth.1

Surgical solutions are needed in both acute and chronic cases when conservative treatments fail.1-5,26 Dacryocystorhinostomy is the gold standard for treating acute adult dacryocystitis.20-23 DCR involves resection of the bony area around the nasolacrimal canal for the purposes of gaining access to the stenotic area within the drainage system. The procedure facilitates the shunting of the tear flow around any blockage by creating a new anastomotic passageway.1-4 The procedure is gaining popularity because it permits the surgeon the ability to immediately drain and culture the abscess. New techniques of completing DCR include endocanalicular laser and endoscopic intranasal surgical techniques.20,26 These revolutionary methods allow the cavity to be accessed without opening the entire passage.26

Clinical Pearls

Epiphora is the term for excessive tearing, which is a principal sign and symptom of nasolacrimal apparatus obstruction.

Cases of epiphora should be evaluated for nasolacrimal apparatus obstruction using the Jones test and fluorescein dye disappearance test.

Dilation and irrigation of the nasolacrimal system should never be attempted during an episode of active infection.

1. Pinar-Sueiro, S, Sota, M, Lerchundi, T et al. Dacryocystitis: Systemic approach to diagnosis and Therapy. Current Infectious Disease Reports. 2012;14(2):137-146.

2. Pinar-Sueiro, S, Fernandez-Hermida, RV, Gibelalde, A, et al. Study on the effectiveness of antibiotic prophylaxis in external dacryocystorhinostomy: A review of 697 cases. Ophthal Plast Reconstr Surg. 2010;26(6):467-72.

3. Paulsen, FP, Thale, AB, Maune, S, Tillmann, BN. New insight into the pathophysiology of primary acquired dacryostenosis. Ophthalmology. 2001;108(12):2329-36.

4. Perry, LJP, Jakobiec, FA, Zakka, FA, et al. Giant dacryocystomucopycele in an Adult: A review of lacrimal sac enlargements with clinical and histopathologic differential diagnoses. Surv Ophthalmol. 2012;57(5):474-85.

5. Martins MC, Ricardo JR, Akaishi PM, Velasco e Cruz AA. Orbital abscess secondary to acute dacryocystitis: case report. Arq Bras Oftalmol. 2008;71(4):576-8.

6. Maheshwari R, Maheshwari S, Shah T. Acute dacryocystitis causing orbital cellulitis and abscess. Orbit. 2009;28(2-3):196-9.

7. Mauriello JA Jr, Wasserman BA. Acute dacryocystitis: an unusual cause of life-threatening orbital intraconal abscess with frozen globe. Ophthal Plast Reconstr Surg 1996 ;12(4):294-5.

8. Ghauri AJ, Keane PA, Scotcher SM, et al. Acute dacryocystitis associated with Epstein-Barr virus infection. Orbit. 2011t;30(5):245-8.

9. Paulsen F. The human nasolacrimal ducts. Adv Anat Embryol Cell Biol. 2003;170:III-XI, 1-106.

10. Van Santvliet L., Ludwig A. Determinants of eye drop size. Surv Ophthalmol 2004;49(2):197-213.

11. Francisco FC, Carvalho AC, Francisco VF, et al. Evaluation of 1000 Lacrmal Ducts by Dacryocystography. Br J Ophthalmol 2007;91(1):43-6.

12. Oyster, CW. The Eyelids and the Lacrimal System. In: Oyster, C.W. The Human Eye Structure and Function. Sunderland Massachusetts, Sinauer Associates, Inc. 1999; 291-320.

13. Cher I. Fluids of the ocular surface: concepts, functions and physics. Clin Experiment Ophthalmol. 2012;40(6):634-43.

14. Zoumalan CI, Joseph JM, Lelli GJ Jr, et al. Evaluation of the canalicular entrance into the lacrimal sac: an anatomical study. Ophthal Plast Reconstr Surg. 2011;27(4):298-303.

15. Paulsen FP, Schaudig U, Thale AB. Drainage of tears: Impact on the ocular surface and lacrimal system. The Ocular Surface. 2003;1(4):180-91.

16. Johnson ME, Murphy PJ. Temporal changes in the tear menisci following a blink. Experimental Eye Research.2006;83:517-25.

17. Sahlin S, Chen E, Kaugesaar T, et al. Effect of eyelid botulinum toxin injection on lacrimal drainage. American Journal of Ophthalmology 2000;129(4):481-486.

18.Zhuang L, Sylvester CL, Simons JP. Bilateral congenital lacrimal fistulae: a case report and review of the literature. Laryngoscope. 2010;120 Suppl 4:S230.

19. Jones LT. An anatomical approach to problems of the eyelids and lacrimal apparatus. Archives of Ophthalmology. 1961.66:137-50.

20. Mandal R, Banerjee AR, Biswas MC, et al. Clinicobacteriological study of chronic dacryocystitis in adults. J Indian Med Assoc. 2008;106(5):296-8.

21. McKeag D, Kamal Z, McNab AA, Sheorey H. Combined coliform and anaerobic infection of the lacrimal sac. Clin Experiment Ophthalmol. 2002;30(1):52-4.

22. Zuberbuhler B, Carifi G, Leatherbarrow B. Acute dacryocystitis in a 2-year old child caused by pantoea. Orbit. 2012;31(1):13-14

23. Deangelis D, Hurwitz J, Mazzulli T. The role of bacteriologic infection in the etiology of nasolacrimal duct obstruction. Can J Ophthalmol. 2001;36(3):134–39.

24. Pinar-Sueiro S, Fernandez-Hermida RV, Gibelalde A, et al. Study on the effectiveness of antibiotic prophylaxis in external dacryocystorhinostomy: A Review of 697 Cases. Ophthal Plast Reconstr Surg. 2010;26(6):467-72.

25. Merkonidis C, Brewis C, Yung M, Nussbaumer M. Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review. Br J Ophthalmol. 2005;89(12):1589-91.

26. Saeed BM. Endoscopic DCR without stents: clinical guidelines and procedure. Eur Arch Otorhinolaryngol. 2012;269(2):545-9.